14 CRR-NY 599.11NY-CRR
14 CRR-NY 599.11
14 CRR-NY 599.11
599.11 Case records.
(a) There shall be a complete case record maintained for each person admitted to a clinic. Such case records shall be maintained in accordance with recognized and accepted principles of recordkeeping as follows:
(1) hard copy case record entries shall be made in non-erasable ink or typed, and shall be legible;
(2) electronic records which use accepted mechanisms for clinician signatures and are maintained in a secure manner, may be utilized. Such records may be kept in lieu of a hard copy case record; and
(3) all entries in case records shall be dated and signed by appropriate staff.
(b) The case record shall be available to all staff of the clinic who are participating in the treatment of the recipient and shall include the following information:
(1) recipient identifying information and history;
(2) preadmission screening notes, as appropriate;
(3) admission note;
(4) diagnosis;
(5) assessment of the recipient's goals regarding psychiatric, physical, social, and/or psychiatric rehabilitation needs;
(6) reports of all mental and physical diagnostic exams, mental health assessments, screenings, tests, and consultations, including risk assessments, health monitoring, and evaluative reports concerning co-occurring developmental, medical, substance use or educational issues performed by the program;
(7) the recipient’s treatment plan;
(8) dated progress notes that relate to goals and objectives of treatment;
(9) dated progress notes that relate to significant events and/or untoward incidents;
(10) periodic treatment plan reviews;
(11) dated and signed records of all medications prescribed by the clinic and other prescription medications being used by the recipient, provided that a failure to include such other prescription medications in the record shall not constitute non-compliance with this requirement if the recipient refuses to disclose such information and such refusal is documented in the case record;
(12) discharge plan;
(13) referrals to other programs and services, if applicable;
(14) consent forms, if applicable;
(15) record of contacts with collaterals if applicable; and
(16) discharge summary within three business days of discharge.
(c) The discharge summary shall be transmitted to the receiving program, where applicable, prior to the arrival of the recipient, or within two weeks, whichever comes first. When circumstances interfere with a timely transmittal of the discharge summary, notation shall be made in the record of the reason for delay. In such circumstances, a copy of all clinical documentation shall be forwarded to the receiving program, as appropriate, prior to the arrival of the recipient.
(d) When a recipient is transferred between programs offered by the same provider, a consolidated record format that follows the recipient may be used.
(e) Records must be retained for a minimum period of six years from the date of the last service in an episode of service.
(f) Information in clinic case records that is subject to the confidentiality protections of Mental Hygiene Law section 33.13 may be shared between facilities, agencies and programs responsible for the provision of services pursuant to an approved local or unified services plan (including programs that receive funding from the office disbursed via a State aid letter); the office and any of the psychiatric centers and programs that it operates; and facilities, agencies, and programs that are not licensed by the office and are not participants in an approved local or unified services plan, but are responsible for the provision of services to any patient pursuant to a written agreement with the office as a party, provided, however, if a case record contains HIV or AIDS information that is protected by Public Health Law article 27-F, or information provided by a federally-funded alcoholism/substance abuse provider that is protected under 42 CFR part 2, such information shall only be redisclosed as permitted by such law or regulation.
14 CRR-NY 599.11
Current through August 15, 2021
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